Case Reports

40-year-old woman • fever • rash • arthralgia • Dx?

Author and Disclosure Information

 

References

What you’ll see. Classical Sweet syndrome usually develops approximately 1 to 3 weeks after an infection—usually an upper respiratory tract or gastrointestinal infection.5 It may also be associated with inflammatory bowel disease or pregnancy.5 Potential symptoms include pyrexia; elevated neutrophil count; papules, nodules, or plaques; and a diffuse infiltrate of predominantly mature neutrophils located in the upper dermis.1,5

Corticosteroid therapy is the gold standard for treatment of classical Sweet syndrome. Dosing usually starts with prednisone 1 mg/kg/d, which can be tapered to 10 mg/d within 4 to 6 weeks.5 If steroid treatment is contraindicated in the patient, alternative treatments are colchicine 0.5 mg 3 times daily for 10 to 21 days or enteric-coated potassium iodide 300 mg 3 times daily until the rash subsides.5 Without treatment, symptoms may resolve within weeks to months; with treatment, the rash usually resolves within 2 to 5 days. Some resistant forms may require 2 to 3 months of treatment.

There is a risk of recurrence in approximately one-third of patients after successful treatment of classical Sweet syndrome.5 Recurrence can be caused by another inciting factor (ie, irritable bowel disease, upper respiratory tract infection, malignancy, or a new medication), making a new investigation necessary. However, treatment would entail the same medications.5

The patient was placed on penicillin V 250 mg twice daily for 5 years due to the significant risk of carditis in the setting of rheumatic fever. She started an oral steroid regimen of a prednisone weekly taper, starting with 60 mg/d, for 4 to 6 weeks. Her papular rash improved soon after initiation of steroid therapy.

THE TAKEAWAY

On presentation, this patient’s symptoms met the Jones criteria for rheumatic fever, but she did not respond to treatment. This led us to revisit her case, order additional tests, and identify a second diagnosis—Sweet syndrome—that responded positively to treatment. This case is a reminder that sometimes the signs and symptoms we are looking at are the result of 2 underlying illnesses, with 1 possibly triggering the other. That was likely what occurred in this case.

CORRESPONDENCE
Farah Leclercq, DO, Department of Family Medicine, University of Florida, 12041 Southwest 1 Lane, Gainesville, FL 32607; farahleclercq@ufl.edu

Pages

Recommended Reading

Pregnancy outcomes on long-acting antiretroviral
MDedge Family Medicine
CAB-LA’s full potential for HIV prevention hits snags
MDedge Family Medicine
HIV vaccine trial makes pivotal leap toward making ‘super antibodies’
MDedge Family Medicine
Flu hospitalizations drop amid signs of an early peak
MDedge Family Medicine
What length antibiotic course for prostatitis?
MDedge Family Medicine